Medicaid documentation do's and don'ts for behavioral health notes
State and federal reviewers can ask for your Medicaid records after the claim is paid. Write each note so a reviewer sees what you did and why.
Head of Growth and Operations, JotPsych
You're writing Medicaid progress notes at the end of a full day, and your template fills most of each one.
Write why this visit was needed
Write down the face-to-face time
Date, time, and sign every note
Let notes read the same each visit
Bill more than the note shows
Audit your own charts
Each item comes from the December 2015 fact sheet of the Centers for Medicare & Medicaid Services (CMS) for behavioral health practitioners who bill Medicaid. The fact sheet's first requirement is that each service meets your state's Medicaid rules, so your notes have to meet those rules too.
Three do's
- Write why this visit was needed. The Centers for Medicare & Medicaid Services (CMS) asks each note to “reflect medical necessity and justify the treatment and clinical rationale” where your state's law requires it. Each state writes its own definition of medical necessity. Write the need for today's visit, not the intake diagnosis alone.
- Write down the face-to-face time. CMS asks for notes that are “complete, concise, and accurate, including the face-to-face time spent with the patient.” Bill the code your recorded minutes support.
- Put a date, a time, and your signature on every note. CMS's list of requirements asks for notes that are “legible, signed, and dated.” CMS's precautions for EHRs add a date and time stamp on every note, “even when updating patient history and life events.” Initial each edit, or mark who made it.
Three don'ts
- Don't let your notes read the same from visit to visit. CMS warns about “cloned” notes, ones “that appear identical for different visits,” and tells you to make sure your auto-fill and keyword features are turned off. Write one detail that's new today. Note a change in symptoms, or in how a medicine is working.
- Don't bill more than your note shows. CMS says to “never bill undocumented services” and never bill “services coded at a higher level than those furnished.” Bill a group session with group codes, and write each attendee's own note.
- Don't audit your own charts. CMS says to “resist being the one to choose and audit your own charts,” because you'll understand your own notes even where the record leaves something out. Have a staff member who knows coding pull a random sample of charts. In solo practice? Ask another clinician in your field to review your charts.
Patient reports anxiety.
Discussed coping skills.
Continue current plan.
Patient reports anxiety.
Discussed coping skills.
Continue current plan.
Panic attacks at work since the dose change.
Practiced paced breathing in session.
Next visit: review work triggers.
CMS warns that notes identical for different visits may not reflect what happened in each one. The rewritten note names what changed since the last visit.
Keep each note ready to send, since federal law has you agree to keep these records and send them when your state or federal reviewers ask.
JotAudit in JotPsych checks your billing codes against your note before you sign, and flags any that don't fit.
Book 15 minutes- Centers for Medicare & Medicaid Services (CMS), Medicaid Documentation for Behavioral Health Practitioners, Medicaid Integrity Education fact sheet, December 2015; read October 2, 2026.
- Social Security Act section 1902(a)(27), 42 U.S.C. 1396a(a)(27): provider agreements to keep records and furnish them to the State agency or the Secretary on request; read October 2, 2026.